Provider Demographics
NPI:1184760498
Name:IMAGE PHYSICAL THERAPY CENTER LLC
Entity type:Organization
Organization Name:IMAGE PHYSICAL THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:BOITUMELO
Authorized Official - Middle Name:P
Authorized Official - Last Name:KGOADI
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:337-857-6178
Mailing Address - Street 1:3527 AMBASSADOR CAFFERY PKWY # 13
Mailing Address - Street 2:BOX 13
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5130
Mailing Address - Country:US
Mailing Address - Phone:337-857-6178
Mailing Address - Fax:
Practice Address - Street 1:3021 VEROT SCHOOL RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-857-6178
Practice Address - Fax:337-857-6592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01833F261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CX09Medicare PIN